Medicaid National Correct Coding Initiative. Edit Design Manual. Page 1 of 54

Transcription

1 Medicaid National Correct Coding Initiative Edit Design Manual /27/2015 Page 1 of 54

2 ` TABLE OF CONTENTS File Types... 4 MII Files File Formats... 4 Publication Files File Formats... 4 File Names... 6 MII Files... 6 CMS Medicaid.gov Publication Files... 7 NCCI Procedure-to-Procedure (PTP) Edits Edit Characteristics... 9 NCCI PTP-Associated Modifiers... 9 Claim Adjudication Rules MII Website Formats NCCI PTP Complete Edit Files Fixed-Width ASCII Text Format Tab-Delimited ASCII Text Format Excel 2007/2010 Format Publication Formats NCCI PTP Complete Edit Files Tab-Delimited ASCII Text Format Excel 2007/2010 Format Publication Formats NCCI PTP Change Report Files Tab-Delimited ASCII Text Format Excel 2007/2010 Format Medically Unlikely Edits (MUEs) Edit Characteristics Claim Adjudication Rules MII Website Formats MUE Complete Edit Files Fixed-Width ASCII Text Format Tab-Delimited ASCII Text Format Excel 2007/2010 Format Publication Formats MUE Complete Edit Files Tab-Delimited ASCII Text Format Excel 2007/2010 Format Publication Formats MUE Change Report Files Tab-Delimited ASCII Text Format Page 2 of 54

3 Excel 2007/2010 Format Appendix A Medicaid Standard Policy Statements for PTP Edits Appendix B Medicaid Rationale for Medically Unlikely Edits Page 3 of 54

4 FILE TYPES There are two types of National Correct Coding Initiative (NCCI) edits: NCCI Procedure-to-Procedure (NCCI PTP) edits Medically Unlikely Edits (MUEs) (units of service) NCCI PTP files and MUE files are prepared for three provider types: Practitioner (PRA) Outpatient Hospital (OPH) Durable Medical Equipment (DME) NCCI PTP and MUE files are prepared for posting to two websites: The Medicaid Integrity Institute (MII) website, which is located on the secure Regional Information Sharing System portal (RISSNET), funded by the United States Department of Justice, and The Medicaid NCCI homepage on the Center for Medicaid and CHIP Services (CMCS) CMS website - Systems/National-Correct-Coding-Initiative.html There are two sets of files: Complete edit files contain a complete replacement file for each quarter s NCCI PTP edits and MUEs, and Change Report files contain a list of only the additions, deletions, revisions, and correct coding modifier indicator changes for the quarterly release. MII Files File Formats The NCCI PTP and MUE files posted to the MII website are prepared in three file formats to allow greatest flexibility for claims processors implementing the edits. o Each file format contains the same records although there may be some difference in the detail or the order of some of the fields. However, the essential information is identical. o Each claims processor should select the file format that best suits their need and use that format consistently when retrieving and implementing the edits. The three formats are: Fixed-Width ASCII text Tab-delimited ASCII text Excel 2007/2010 Publication Files File Formats There are two sets of publication files posted to the CMS public website at These include: NCCI PTP and MUE complete edit files and NCCI PTP and MUE Quarterly Change Report files Page 4 of 54

5 NCCI PTP and MUE Complete Edit Files The quarterly NCCI PTP and MUE complete edit files posted to the CMS public website at are prepared in two file formats. o Each file format contains the same records and the field order remains the same. o These files mirror the format of their counterparts on the CMS Medicare website. o Each user can select the file format that best suits their need. The two formats are: Tab-delimited ASCII text Excel 2007/2010 NCCI PTP and MUE Change Report Files With each quarterly edit file release, publication Change Report files are produced and posted to the CMS Medicaid.gov website for providers, and other interested parties. The Change Report files are intended to provide a summary of all additions, deletions, revisions, and modifier indicator changes effective for the quarter. States should not use the Change Report files to update their NCCI edit files. These files are prepared in two file formats: o Each file format contains the same records and the field order remains the same. o Each user can select the file format that best suits their need. The two formats are: Tab-delimited ASCII text Excel 2007/2010 Important Note: State Medicaid agencies should only use the quarterly Medicaid NCCI complete edit files that are posted on the MII website to process their Medicaid claims and not the complete edit quarterly Medicaid NCCI files posted on the CMS website. The quarterly Medicaid NCCI files that are posted on the MII website can ONLY be downloaded by a state Medicaid agency. Page 5 of 54

6 MII Files FILE NAMES For the complete edit files posted to the MII website, the naming convention that will be used is: Payer - MCD = Medicaid Type of Edit - PTP or MUE Provider type - PRA (Practitioner), OPH (Outpatient Hospital), or DME (Durable Medical Equipment) Version number Year and quarter # (1, 2, 3, 4) Release type and rendition number F = Final e.g., F1 = first rendition of final file (If there is a subsequent revision to a quarterly file, it would be designated F2.) Format - T = Fixed-Width ASCII Text; D = Tab-Delimited ASCII Text; E = Excel 2007/2010 File extension -.txt Fixed-Width ASCII Text and Tab-Delimited ASCII Text;.xlsx Excel For example, the initial final versions of the January 2013 MII website files were named: MCD-PTP-PRA-v2013q1-F1-T.txt MCD-PTP-PRA-v2013q1-F1-D.txt MCD-PTP-PRA-v2013q1-F1-E.xlsx MCD-PTP-OPH-v2013q1-F1-T.txt MCD-PTP-OPH-v2013q1-F1-D.txt MCD-PTP-OPH-v2013q1-F1-E.xlsx MCD-PTP-DME-v2013q1-F1-T.txt MCD-PTP-DME-v2013q1-F1-D.txt MCD-PTP-DME-v2013q1-F1-E.xlsx MCD-MUE-PRA-v2013q1-F1-T.txt MCD-MUE-PRA-v2013q1-F1-D.txt MCD-MUE-PRA-v2013q1-F1-E.xlsx MCD-MUE-OPH-v2013q1-F1-T.txt MCD-MUE-OPH-v2013q1-F1-D.txt MCD-MUE-OPH-v2013q1-F1-E.xlsx MCD-MUE-DME-v2013q1-F1-T.txt MCD-MUE-DME-v2013q1-F1-D.txt MCD-MUE-DME-v2013q1-F1-E.xlsx Page 6 of 54

7 CMS - Medicaid.gov Publication Files Medicaid NCCI Edit Design Manual For the complete edit Publication files posted to the CMS Medicaid website, Medicaid.gov, the naming convention that will be used is: Payer - MCD = Medicaid Type of Edit - PTP or MUE Provider type Practitioner Services, Outpatient Hospital Services, or DME Effective date Effective_mmddyyyy File extension -.txt Tab-Delimited ASCII Text;.xlsx Excel For example, the January 2013 Publication files were named: MCD-PTP-PractitionerServices-Effective_ txt MCD-PTP-PractitionerServices-Effective_ xlsx MCD-PTP-OutpatientHospitalServices-Effective_ txt MCD-PTP-OutpatientHospitalServices-Effective_ xlsx MCD-PTP-DMEServices-Effective_ txt MCD-PTP-DMEServices-Effective_ xlsx MCD-MUE-PractitionerServices-Effective_ txt MCD-MUE-PractitionerServices-Effective_ xlsx MCD-MUE-OutpatientHospitalServices-Effective_ txt MCD-MUE-OutpatientHospitalServices-Effective_ xlsx MCD-MUE-DMEServices-Effective_ txt MCD-MUE-DMEServices-Effective_ xlsx For Change Report Publication files posted to the CMS Medicaid website, Medicaid.gov, the naming convention that will be used is: Payer - MCD = Medicaid Type of Edit - PTP or MUE Provider type Practitioner Services (PRA), Outpatient Hospital Services (OPH), or DME (DME) Change Type Additions (Adds), Deletions (Dels), Revisions (Revs), CCMI (modifier indicator) changes Effective date Effective_mmddyyyy File extension -.txt Tab-Delimited ASCII Text or.xlsx Excel For example, the January 2013 Change Report Publication files were named: MCD_PTP_PRA_Adds_Eff_ txt MCD_PTP_PRA_Dels_Eff_ txt MCD_PTP_PRA_CCMI_Changes_Eff_ txt MCD_PTP_PRA_Changes_Eff_ xlsx Page 7 of 54

8 MCD_PTP_OPH_Adds_Eff_ txt MCD_PTP_OPH_Dels_Eff_ txt MCD_PTP_OPH_CCMI_Changes_Eff_ txt MCD_PTP_OPH_Changes_Eff_ xlsx MCD_PTP_DME_Adds_Eff_ txt MCD_PTP_DME_Dels_Eff_ txt MCD_PTP_DME_CCMI_Changes_Eff_ txt MCD_PTP_DME_Changes_Eff_ xlsx MCD_MUE_PRA_Adds_Eff_ txt MCD_MUE_PRA_Dels_Eff_ txt MCD_MUE_PRA_Rev_Eff_ txt MCD_MUE_PRA_Changes_Eff_ xlsx MCD_MUE_OPH_Adds_Eff_ txt MCD_MUE_OPH_Dels_Eff_ txt MCD_MUE_OPH_Rev_Eff_ txt MCD_MUE_OPH_Changes_Eff_ xlsx MCD_MUE_DME_Adds_Eff_ txt MCD_MUE_DME_Dels_Eff_ txt MCD_MUE_DME_Rev_Eff_ txt MCD_MUE_DME_Changes_Eff_ xlsx Note: In the text (.txt) format, each Change Report is formatted individually. Therefore, additions, deletions, revisions, and CCMI changes are contained in separate files. The Excel (.xlsx) format contains a single file with separate tab for each change type i.e., additions (Adds), deletions (Dels), revisions (Revs), CCMI Changes (CCMIChgs). Page 8 of 54

9 NCCI PROCEDURE-TO-PROCEDURE (PTP) EDITS Edit Characteristics (1) NCCI PTP edits apply to services by same provider to same beneficiary on same date of service. The edits apply regardless of whether the codes are reported on the same claim or on different claims. (2) Each edit consists of a code pair (column one code and column two code), a policy statement, the CLEID, an effective date, a deletion date if applicable, and a modifier indicator. (a) Column one HCPCS/CPT code (b) Column two IPCS/CPT code (c) Policy statement The coding rationale for the edit (d) CLEID Correspondence Language Example Identification number for correspondence (e) Effective date The date that an edit was initially implemented. Claims with dates of service on or after this date and on or before the deletion date (if any) must be subject to the edit. (f) Deletion date The last date that an edit is active. Claims with dates of service on or before the deletion date and on or after the effective date must be subject to the edit. Claims with dates of service after the deletion date are not subject to the (g) edit. Modifier indicator (CCMI) (i) 0 Edit cannot be bypassed with an NCCI PTP-associated modifier. (See sections below on NCCI PTP-Associated Modifiers and Claim Adjudication Rules.) (ii) 1 Edit may be able to be bypassed with an NCCI PTP-associated modifier. (See sections below on NCCI PTP-Associated Modifiers and Claim Adjudication Rules.) (iii) 9 The edit was deleted retroactive to its implementation date. The edit pair is not active and should not be the basis for denying either code of the edit. (3) The presence of a HCPCS/CPT code in a PTP edit does not necessarily indicate that the code is covered by any state Medicaid program or by all state Medicaid programs. NCCI PTP-Associated Modifiers The NCCI PTP-associated modifiers are the following: Anatomical modifiers: RT, LT, E1 E4, FA, F1 F9, TA, T1 T9, LC, LD, LM, RC, RI Non-anatomical modifiers: 24, 25, 27, 57, 58, 59, 78, 79, 91, XE, XP, XS, XU The state s claims processing system must recognize all of these modifiers and allow the PTP edit to be bypassed, if any of these modifiers is appended to the appropriate code of the edit pair with a modifier indicator of 1 and if the other conditions specified in the Claim Adjudication Rules section below are met. Failure to do this will result in incorrect denials of payment that will be incorrectly attributed to NCCI. Page 9 of 54

10 PTP-associated modifiers may be appended if and only if appropriate, based on clinical circumstances, and in accordance with the NCCI program and HCPCS/CPT Manual instructions/definitions for the modifier/ procedure code combination. For example, modifier 25 (significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should only be appended to an evaluation and management (E&M) code ( , ), regardless of whether the E&M code is the column 1 or column 2 code. It would never be appropriate for use with other codes, such as surgery codes. Medicaid NCCI does not require that modifier 59 be appended to the column two code of a PTP edit. It may be appended to either the column one or the column two code. States, providers, and other interested parties should also refer to the Modifier 59 article and the NCCI Policy Manual for Medicaid Services for specific information regarding modifier usage, which can be found on the Medicaid.gov website at Correct-Coding-Initiative.html. Claim Adjudication Rules (1) Apply edits to claims for services by the same provider to the same beneficiary on the same date of service. (2) Determine whether type of claim and site of service are subject to the NCCI PTP edits. (a) The Practitioner NCCI PTP edit file should be applied to Medicaid claims from: - practitioners, in which a unique provider identification number for an individual practitioner is associated with each claim line, regardless of the site of service, and - ambulatory surgical centers. (b) The Outpatient Hospital NCCI PTP edit file should be applied to Medicaid claims: - from outpatient hospitals and - for facility (hospital) emergency department, observation, and hospital laboratory services. (c) States have the option of applying the Outpatient Hospital NCCI PTP edit file to provider types other than those described in (2)(a), (2)(b), or (2)(d) that submit claims in which a unique provider number for an individual practitioner is not associated (d) with each claim line. Either the Durable Medical Equipment, Practitioner, or Outpatient Hospital NCCI PTP edit file should be applied to Medicaid claims for durable medical equipment, prosthetics, orthotics, and supplies. Identical edits for these items are present in all three of these files. (3) For each HCPCS/CPT code submitted on a claim, identify all other HCPCS/CPT codes submitted on the current claim or earlier claims in history with the same date of service for the same provider and same beneficiary. This is the subset of HCPCS/CPT codes for each code that needs to be tested against the NCCI procedure-to-procedure edit files. (a) For each code in the subset, use it as a column one code and pair it with every other code in the subset as a column two code. Each code is paired with every other code as both column one and column two codes. (Note that this method identifies code pairs such that each code as a column one code is paired with every other code as a column two code AND each code as a column two code is paired with every other code as a column one code.) Determine whether any of these code pairs match any of Page 10 of 54

11 (b) (c) (d) (e) (f) the code pair edits in the appropriate NCCI PTP edit file for the relevant site of service. After code pairs that match NCCI PTP edits in the edit file are identified, test the date of service against the effective date and deletion date (if relevant) for each edit. Apply the NCCI PTP edit to the claim only if the date of service is on or after the effective date and on or before the deletion date of the edit. Most edits do not have deletion dates. After code pairs that match PTP edits in the edit file with dates of service within the effective period of the corresponding edit are identified, determine whether the column one code is eligible for payment. Apply the NCCI PTP edit to the claim only if the column one code is eligible for payment. Bypass the PTP edit if it is not. After code pairs that match NCCI PTP edits in the edit file with dates of service within the effective period of the corresponding edit and with a column one code that is eligible for payment are identified, determine whether an NCCI PTP-associated modifier is correctly appended to either or both of the codes of the code pair. Proceed as follows: (i) If the modifier indicator of the edit is 0, the column two code is denied (not payable) regardless of whether an NCCI PTP-associated modifier is (ii) appended. These edits cannot be bypassed. If the modifier indicator of the edit is 1 and if no NCCI PTP-associated modifier is correctly appended to either code, the column two code is denied. (iii) If the modifier indicator of the edit is 1 and if an NCCI PTP-associated modifier is correctly appended to an appropriate code in the edit, the PTP edit is bypassed and the column two code is eligible for payment. An exception to this rule is that if both codes have the same anatomical modifier (see above) and neither code has modifier 58, 59, 78, 79, XE, XP, XS, or XU, the PTP edit is NOT bypassed and the column two code is denied. (iv) If the modifier indicator of the edit is 9, both codes are eligible for payment. The corresponding edit is inactive and was deleted retroactive to its implementation date. If a code is denied because of an NCCI PTP edit, a denial message should be added to the code denial on the provider payment notice. Some recommendations follow: (i) Provider Payment Notice Advice alternatives: i. Payment denied based on NCCI edit. ii. Payment denied because service not payable with another service on the same date of service. iii. Do NOT state: Payment denied because service is component of another service (or integral to another service) on same date of service. Most NCCI PTP edits are NOT based on one service being a component of another more comprehensive service or one service being integral to another service. There should also be a notice on the claim payment advice indicating that the denied service SHOULD NOT be billed to the beneficiary. The denied service is a provider liability. Providers cannot use any type of an Advanced Beneficiary Notice or Waiver form to obtain payment from beneficiary. Page 11 of 54

12 Because reported HCPCS/CPT codes for the same date of service on the current claim are tested with all other codes with the same date of service from claims in history, it is possible that an NCCI PTP edit will be triggered where the column one code on the current claim is payable and the column two code that should have been denied was previously paid from a claim in history that was adjudicated earlier. In this situation, the claims processor must see to it that the prior inappropriate payment for the column two code is recouped, offset, or otherwise adjusted, so that the provider receives appropriate payment for only the column one code. A state s Medicaid Management Information System (MMIS) should be configured to enable it to apply three types of edits to Medicaid claims in the following order: (1) State and contractor Medicaid edits, other than those identified in (2) and (3) below. These edits include, but are not limited to, edits that screen incoming claims for duplicate services, missing information, and modifiers which are inappropriately appended to a HCPCS/CPT code and edits that address eligibility, invalid HCPCS/CPT codes, coverage, medical necessity, and prior authorization (if required). (2) Medicaid NCCI PTP edits and MUEs (3) State and contractor PTP edits and unit-of-service (UOS) edits Page 12 of 54

13 MII WEBSITE FORMATS NCCI PTP COMPLETE EDIT FILES The NCCI Procedure-to-Procedure (PTP) complete edit files are posted to the MII website in three formats. The specifications for each format and sample screen prints have been included on the following pages. The three formats are: 1. Fixed-Width ASCII Text 2. Tab-Delimited ASCII Text 3. Excel 2007/2010 Fixed-Width ASCII Text Format (1) In the NCCI procedure-to-procedure (PTP) MII website edit files in fixed-width ASCII text format, each edit will have the following format: (2) There will be three separate final NCCI PTP MII website edit files. Their file names will be: a. Practitioner/ASC NCCI PTP edit file: MCD-PTP-PRA-vXXXXqX-FX-T.txt b. Outpatient Hospital NCCI PTP edit file: MCD-PTP-OPH-vXXXXqX-FX-T.txt c. Durable Medical Equipment (DME) NCCI PTP edit file: MCD-PTP-DME-vXXXXqX-FX-T.txt Note: Refer to page 7 for details of file naming convention. Field Name Notes Type Beg. Char # of Char Column 1 code (no label) AAAAA Alpha-Numeric Text 1 5 Column 2 code (no label) BBBBB Alpha-Numeric Text 6 5 Standard Policy Statement (no label) CCCCCCCCCCCCCCCCCCCCCCCCC CCCCCCCCCCCCCCCCCCCCCCCCC CCCCCCCCCC Each statement is coded to a policy number. On active edits, this policy number directly relates to the first 2 digits of the CLEID number. A list of these Standard Policy Statements can be found in Appendix A. Alpha-Numeric Text Page 13 of 54

14 Field Name Notes Type Beg. Char # of Char CLEID (no label) Correspondence Language Example Identification number Alpha-Numeric Text format: DD.EEEEEEEEE The first 2 digits correspond to the Standard Policy Statement for the edit. The digits following the. correspond to the section of the Medicaid Correspondence Language Manual from which an example can be extracted to incorporate into correspondence such as provider inquiry responses. The last four characters of the CLEID field may contain empty spaces. When a PTP edit is terminated, the CLEID will be changed to 13.DELETEPR4, which corresponds to the delete edit language and example in the Correspondence Language Manual. Effective Date (no label) Julian date format: yyyyddd Numeric 83 7 Deletion Date (no label) Correct Coding Modifier Indicator (no label) Julian date format: yyyyddd Edits with <blank> Deletion Date values are ACTIVE from the date in the Effective Date field. Indicated in the example as I Valid values = 0, 1, or 9 0 = modifiers not allowed 1 = modifiers allowed 9 = Edit terminated retroactively, edit does not apply Numeric 90 7 Numeric 97 1 Page 14 of 54

15 The following is an example of a section of a fixed-width ASCII text NCCI PTP MII website edit file: Page 15 of 54

16 Tab-Delimited ASCII Text Format Medicaid NCCI Edit Design Manual (1) In the NCCI procedure-to-procedure (PTP) MII website edit files in tab-delimited ASCII text format, each edit will have the following format: (2) There will be three separate final NCCI PTP MII website edit files. Their file names will be: a. Practitioner/ASC NCCI PTP edit file: MCD-PTP-PRA-vXXXXqX-FX-D.txt b. Outpatient Hospital NCCI PTP edit file: MCD-PTP-OPH-vXXXXqX-FX-D.txt c. Durable Medical Equipment (DME) NCCI PTP edit file: MCD-PTP- DME-vXXXXqX-FX- D.txt Note: Refer to page 7 for details of file naming convention. Field Name Notes Type Delimiter # of Char Column 1 code (labeled Col1) AAAAA Alpha- Numeric Text 5 Column 2 code (labeled Col2) BBBBB Alpha- Numeric Text tab 5 Effective Date (labeled EffDt) Deletion Date (labeled DelDt) Correct Coding Modifier Indicator (labeled Mod Ind) Gregorian Year (y), Month (m) Day (d) format: yyyymmdd Gregorian Year (y), Month (m) Day (d) format: yyyymmdd Edits with <blank> Deletion Date values are ACTIVE from the date in the Effective Date field. Indicated in the example as I Valid values = 0, 1, or 9 0 = modifiers not allowed 1 = modifiers allowed 9 = Edit terminated retroactively, edit does not apply Numeric tab 8 Numeric tab 8 Numeric tab 1 Page 16 of 54

17 Field Name Notes Type Delimiter # of Char CLEID Correspondence Language Example Identification number Alpha- Numeric Text tab 12 format: DD.EEEEEEEEE The first 2 digits correspond to the Standard Policy Statement for the edit. The digits following the. correspond to the section of the Medicaid Correspondence Language Manual from which an example can be extracted to incorporate into correspondence such as provider inquiry responses. The last four characters of the CLEID field may contain empty spaces. When a PTP edit is terminated, the CLEID will be changed to 13.DELETEPR4, which corresponds to the deleted edit language and example in the Correspondence Language Manual. Documents and web postings containing these tab-delimited ASCII text files should include the following notification: Please note In tab-delimited text files, the records may not align with the column headings or from row to row. This is because of the logic that tells the computer where to place certain values when the data is imported into other applications. For example, on rows for edits that do not have a deletion date, the Correct Coding Modifier Indicator will appear aligned. But, on rows for edits that do have a deletion date, the Correct Coding Modifier Indicator will appear to shift to the right. Even though they appear skewed to the reader s eye, from a programming standpoint, the Correct Coding Modifier Indicator in both lines will be in the same position. Page 17 of 54

18 The following is an example of a section of a tab-delimited ASCII text NCCI PTP MII website edit file: Page 18 of 54

19 Excel 2007/2010 Format (1) In the NCCI procedure-to-procedure (PTP) MII website edit files in Excel 2007/2010 format, each edit will have the following format: (2) There will be two separate final NCCI PTP MII website edit files. Their file names will be: a. Practitioner/ASC NCCI PTP edit file: MCD-PTP-PRA-vXXXXqX-FX-E.xlsx b. Outpatient Hospital NCCI PTP edit file: MCD-PTP-OPH-vXXXXqX-FX-E.xlsx c. Durable Medical Equipment (DME) NCCI PTP edit file: MCD-PTP-DME-vXXXXqX-FX- D.txt Note: Refer to page 7 for details of file naming convention. Column Name Notes Type Column 1 code AAAAA Alpha-Numeric Text (labeled Column 1) Column 2 code (labeled Column 2) Effective Date Deletion Date Correct Coding Modifier Indicator (labeled Modifier Indicator) BBBBB Gregorian Year (y), Month (m) Day (d) format: yyyymmdd Gregorian Year (y), Month (m) Day (d) format: yyyymmdd Edits with <blank> Deletion Date values are ACTIVE from the date in the Effective Date field. Indicated in the example as I Valid values = 0, 1, or 9 0 = modifiers not allowed 1 = modifiers allowed 9 = Edit terminated retroactively, edit does not apply Alpha-Numeric Text Numeric Numeric Numeric Page 19 of 54

20 Column Name Notes Type CLEID Correspondence Language Example Alpha-Numeric Text Identification number format: DD.EEEEEEEEE The first 2 digits correspond to the Standard Policy Statement for the edit. The digits following the. correspond to the section of the Medicaid Correspondence Language Manual from which an example can be extracted to incorporate into correspondence such as provider inquiry responses. The last four characters of the CLEID field may contain empty spaces. When an edit is terminated, the CLEID will be changed to 13.DELETEPR4, which corresponds to the deleted edit language and example in the Correspondence Language Manual. The following is an example of a section of an Excel 2007/2010 NCCI PTP MII website edit file: Page 20 of 54

21 PUBLICATION FORMATS NCCI PTP COMPLETE EDIT FILES The NCCI Procedure-to-Procedure (PTP) complete edit files are posted to the CMS Medicaid.gov website in two formats. The specifications for each format and sample screen prints have been included on the following pages. The two formats are: 1. Tab-Delimited ASCII Text 2. Excel 2007/2010 Tab-Delimited ASCII Text Format (1) In the NCCI procedure-to-procedure (PTP) Publication edit files in tab-delimited ASCII text format, each edit will have the following format: (2) There will be three separate NCCI PTP Publication edit files. The tab-delimited ASCII text publication files do not indicate a version number, but rather include the date the file becomes effective. Their file names will be: a. Practitioner/ASC NCCI PTP edit file: MCD-PTP-PractitionerServices- Effective_mmddyyyy.txt b. Outpatient Hospital NCCI PTP edit file: MCD-PTP-OutpatientHospitalServices- Effective_mmddyyyy.txt c. Durable Medical Equipment (DME) NCCI PTP edit file: MCD-PTP-DMEServices- Effective_mmddyyyy.txt Note: Refer to page 7 for details of file naming convention. Field Name Notes Type Delimiter # of Char Column 1 code (labeled Col1) AAAAA Alpha- Numeric Text 5 Column 2 code (labeled Col2) BBBBB Alpha- Numeric Text tab 5 Effective Date (labeled EffDt) Gregorian Year (y), Month (m) Day (d) format: yyyymmdd Numeric tab 8 Page 21 of 54

22 Field Name Notes Type Delimiter # of Char Deletion Date (labeled DelDt) Gregorian Year (y), Month (m) Day (d) format: yyyymmdd Numeric tab 8 Edits with <blank> Deletion Date values are ACTIVE from the date in the Effective Date field. Correct Coding Modifier Indicator (labeled Mod Ind) Indicated in the example as I Valid values = 0, 1, or 9 0 = modifiers not allowed 1 = modifiers allowed 9 = Edit terminated retroactively, edit does not apply Numeric tab 1 Notes: 1. Files for publication on the CMS website, Medicaid.gov, will not include the CLEID because this information is intended for internal claims processor use only. 2. In addition, publication files will include the following copyright disclaimer notice in the header of the file: "Current Procedural Terminology 20xx American Medical Association. All Rights Reserved. Current Procedural Terminology (CPT) is copyright 20xx American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association." FYI: The format above (including the quotation marks) is how the disclaimer appears when copied and pasted from the tab-delimited ASCII Text file. In the file itself, the disclaimer appears as a single, long string of text, including hidden characters which result in the positioning of spaces and line returns. Page 22 of 54

23 The following is an example of a section of a tab-delimited ASCII text NCCI PTP Publication edit file: Documents and web postings containing these tab-delimited ASCII text files should include the following notification: Please note In tab-delimited text files the records may not align with the column headings or from row to row. This is because of the logic that tells the computer where to place certain values when the data is imported into other applications. For example, on rows for edits that do not have a deletion date, the Correct Coding Modifier Indicator will appear aligned. But, on rows for edits that do have a deletion date, the Correct Coding Modifier Indicator will appear to shift to the right. Even though they appear skewed to the reader s eye, from a programming standpoint, the Correct Coding Modifier Indicator in both lines will be in the same position. Also, note Depending on whether the end-user has checked or unchecked the format Word Wrap option, the AMA Copyright and Disclaimer information that appears on line 2 of the above example may appear as either a single line or as a variable number of lines depending on how the user has the window displayed. Again, this is simply a reader s eye perception. From a programming standpoint, because the AMA Copyright and Disclaimer information is preceded by a quotation mark ( ) and followed by a quotation mark ( ), the computer will recognize this header information as a single unit and treat it accordingly. Page 23 of 54

24 Excel 2007/2010 Format (1) In the NCCI procedure-to-procedure (PTP) Publication edit files in Excel 2007/2010 format, each edit will have the following format: (2) There will be three separate NCCI PTP Publication edit files. The Excel 2007/2010 publication files do not indicate a version number, but rather include the date the file becomes effective. Their file names will be: a. Practitioner/ASC NCCI PTP edit file: MCD-PTP-PractitionerServices- Effective_mmddyyyy.xlsx b. Outpatient Hospital NCCI PTP edit file: MCD-PTP-OutpatientHospitalServices- Effective_mmddyyyy.xlsx c. Durable Medical Equipment Provider Services (DME) NCCI PTP edit file: MCD-PTP- DMEServices-Effective_mmddyyyy.txt Note: Refer to page 7 for details of file naming convention. Column Name Notes Type Column 1 code AAAAA Alpha-Numeric (labeled Column 1) Text Column 2 code (labeled Column 2) Effective Date BBBBB Gregorian Year (y), Month (m) Day (d) format: yyyymmdd Alpha-Numeric Text Numeric Page 24 of 54

25 Column Name Notes Type Deletion Date Gregorian Year (y), Month (m) Day (d) Numeric format: yyyymmdd Edits with <blank> Deletion Date values are ACTIVE from the date in the Effective Date field. Correct Coding Modifier Indicator (labeled Modifier Indicator) Indicated in the example as I Valid values = 0, 1, or 9 0 = modifiers not allowed 1 = modifiers allowed 9 = Edit terminated retroactively, edit does not apply Numeric Notes: (1) Files for publication on the CMS website, Medicaid.gov, will not include the CLEID because this information is intended for internal claims processor use only. (2) In addition, publication files will include the following copyright disclaimer notice in the header of the file: Current Procedural Terminology 20xx American Medical Association. All Rights Reserved. Current Procedural Terminology (CPT) is copyright 20xx American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. NOTE: The format above is copied directly from the Excel format file. Page 25 of 54

26 The following is an example of a section of an Excel 2007/2010 NCCI PTP Publication edit file: Page 26 of 54

27 PUBLICATION FORMATS NCCI PTP CHANGE REPORT FILES The NCCI Procedure-to-Procedure (PTP) Change Report files are posted to the CMS Medicaid.gov website in two formats. The specifications for each format and sample screen prints have been included on the following pages. The two formats are: 1. Tab-Delimited ASCII Text 2. Excel 2007/2010 Tab-Delimited ASCII Text Format (1) In the NCCI procedure-to-procedure (PTP) Publication Change Report files in tab-delimited ASCII text format, each file will have the following format: (2) There will be nine separate NCCI PTP Publication Change Report files in this format. The tabdelimited ASCII text publication files do not indicate a version number, but rather include the date the file becomes effective. (3) In this format, there will be separate files for each provider type (PRA/OPH/DME) and for each change type (additions, deletions, CCMI changes). Refer to page 7 for details of the file naming convention and the complete list of file names. Field Name Notes Type Delimiter # of Char Column 1 code (labeled Col1) AAAAA Alpha- Numeric Text 5 Column 2 code (labeled Col2) BBBBB Alpha- Numeric Text tab 5 Correct Coding Modifier Indicator (labeled Mod Ind) Indicated in the example as I Valid values = 0, 1, or 9 0 = modifiers not allowed 1 = modifiers allowed 9 = Edit terminated retroactively, edit does not apply Numeric tab 1 Page 27 of 54

28 The following is an example of a section of a tab-delimited ASCII text NCCI PTP Change Report file: Documents and web postings containing these tab-delimited ASCII text files should include the following notification: Please note In tab-delimited text files the records may not align with the column headings or from row to row. This is because of the logic that tells the computer where to place certain values when the data is imported into other applications. For example, on rows for edits that do not have a deletion date, the Correct Coding Modifier Indicator will appear aligned. But, on rows for edits that do have a deletion date, the Correct Coding Modifier Indicator will appear to shift to the right. Even though they appear skewed to the reader s eye, from a programming standpoint, the Correct Coding Modifier Indicator in both lines will be in the same position. Also, note Depending on whether the end-user has checked or unchecked the format Word Wrap option, the AMA Copyright and Disclaimer information that appears on line 2 of the above example may appear as either a single line or as a variable number of lines depending on how the user has the window displayed. Again, this is simply a reader s eye perception. From a programming standpoint, because the AMA Copyright and Disclaimer information is preceded by a quotation mark ( ) and followed by a quotation mark ( ), the computer will recognize this header information as a single unit and treat it accordingly. Page 28 of 54

29 Excel 2007/2010 Format (1) In the NCCI procedure-to-procedure (PTP) Publication Change Report file in Excel 2007/2010 format, each file will have the following format: (2) There will be three separate NCCI PTP Publication Change Report files. The Excel 2007/2010 publication files do not indicate a version number, but rather include the date the file becomes effective. Each Excel file will contain three worksheets/tabs to identify additions, deletions, and CCMI changes. The file names will be: a. Practitioner/ASC NCCI PTP edit file: MCD_PTP_PRA_Changes_Eff_mm-dd-yyyy.xlsx b. Outpatient Hospital NCCI PTP edit file: MCD_PTP_OPH_Changes_Eff_mm-ddyyyy.xlsx c. Durable Medical Equipment (DME) NCCI PTP edit file: MCD_PTP_DME_Changes_Eff_mm-dd-yyyy.xlsx Note: Refer to page 7 for complete details regarding file naming conventions. Column Name Notes Type Column 1 code AAAAA Alpha-Numeric (labeled Column 1) Text Column 2 code (labeled Column 2) BBBBB Alpha-Numeric Text Page 29 of 54

30 Column Name Notes Type Correct Coding Modifier Indicator (labeled Modifier Indicator) Indicated in the example as I Valid values = 0, 1, or 9 0 = modifiers not allowed 1 = modifiers allowed 9 = Edit terminated retroactively, edit does not apply Numeric Notes: (1) In addition, publication files will include the following copyright disclaimer notice in the header of the file: Current Procedural Terminology 20xx American Medical Association. All Rights Reserved. Current Procedural Terminology (CPT) is copyright 20xx American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. NOTE: The format above is copied directly from the Excel format file. The following is an example of a section of an Excel 2007/2010 NCCI PTP Change Report file: Page 30 of 54

31 MEDICALLY UNLIKELY EDITS Edit Characteristics (1) An MUE is a unit of service (UOS) edit for a HCPCS/CPT code that applies to services performed by the same provider for the same beneficiary on the same date of service. (2) An MUE is a claim line edit, NOT an entire claim edit. That is, the MUE is applied separately to the UOS reported on each line of a claim. It is NOT applied to the sum total UOS for a code on the entire claim. (3) An MUE is NOT a date of service edit. It is not applied to the sum of all UOS for a code with the same date of service. It is a claim line edit. (4) Each edit consists of a HCPCS/CPT code, an MUE value, an effective date, a deletion date, CLEID, and publication indicator. (a) HCPCS/CPT code (b) (c) (d) (e) (f) The MUE value for the HCPCS/CPT code. Effective date The date that each edit was first implemented. Claims with dates of service on or after this date and on or before the deletion date, if any, must be subject to the edit. Deletion date The last date that an edit is active. Claims with dates of service on or before this date and on or after the effective date are subject to the edit. Claims with dates of service after the deletion date are not subject to the edit. CLEID Correspondence Language Example Identification number for correspondence. Publication Indicator This indicator enables a claims processor to determine whether an MUE value is published. If the value is NOT published on the CMS website, it is a confidential MUE value and should NOT be shared with/released to anyone other than Medicaid Fiscal Agent contractors with a valid need for the MUE value. Medicaid currently does not have any confidential/non-published MUE values. However, confidential / non-published Medicaid MUEs may be implemented at a later date. (5) The presence of an MUE value for a HCPCS/CPT code does not necessarily indicate that the code is covered by any or all state Medicaid programs. Page 31 of 54

32 MEDICALLY UNLIKELY EDITS Claim Adjudication Rules (1) Apply edits to services by same provider for same beneficiary on same date of service. (2) Determine whether the type of claim and the site of service are subject to MUE edits. (a) The Practitioner MUE file should be applied to Medicaid claims from: - practitioners, in which a unique provider identification number for an individual practitioner is associated with each claim line, regardless of the site of service, and - ambulatory surgical centers. (b) The Outpatient Hospital MUE file should be applied to Medicaid claims: - from outpatient hospitals and - for facility (hospital) emergency department, observation, and hospital laboratory services. (c) States have the option of applying the Outpatient Hospital MUE file to provider types other than those described in (2)(a), (2)(b), or (2)(d) that submit claims in which a unique provider number for an individual practitioner is not associated with each claim line. (d) Either the Durable Medical Equipment, Practitioner, or Outpatient Hospital MUE file should be applied to Medicaid claims for durable medical equipment, prosthetics, orthotics, and supplies. Identical edits for these items are present in all three of these files. (3) An MUE is a claim line edit that compares the UOS (unit of service) reported for the HCPCS/CPT code on the claim line to the MUE value for that code. (4) If the UOS on the claim line are less than or equal to the MUE value assigned to the HCPCS/CPT code, the UOS pass the MUE. (5) If the UOS on the claim line is greater than the MUE value assigned to the HCPCS/CPT code, the UOS fail the MUE and the entire claim line is denied. That is, no UOS are paid for the code reported on that claim line. (6) Statements (3)-(5) apply to claim lines where the From date to the To date are the same. However, if a code subject to an MUE is reported with a different From date and To date on the claim line, the claims processor should divide the reported units of service by the number of days in the date span and round to the nearest whole number. This number is compared to the MUE value for the code on the claim line and the rules stated in (4) and (5) above are applied substituting this calculated number for the submitted UOS. For example, the provider bills a HCPCS/CPT code which has an MUE value of 1. The From date listed on the claim is 02/01/2012 and the To date listed on the claim is 02/10/2012. The submitted units of service (UOS) on the claim are 14. The From and To dates equal 10 day date span. The number of units of service (14) should be divided by the number of days in the date span (10) to determine the per day units of service. In this example, the per day units of service equal 1.4. Rounding to the nearest whole number makes the per day units of service equal 1, which should pass the MUE edit. However, a claim with the same From and To dates as that listed above (10 day date span) billed with 20 submitted units of service would calculate to equal 2 units of service per day. This number exceeds the MUE value for the code and the entire claim line should be denied. (7) If a claim line is denied (not paid) because of an MUE edit, a denial message should be added to the code denial on the provider payment notice. Some recommendations follow: (a) Provider Payment Notice Advice alternatives: Page 32 of 54

33 (i) Units of service exceed limit. (ii) Units of service exceed medically unlikely edit. (8) There should also be a notice on the provider claim payment advice indicating that a denied service SHOULD NOT be billed to the beneficiary. Providers cannot use any type of Recipient Waiver of Liability or Advanced Beneficiary Notice to obtain payment from the beneficiary. (9) Caution: Since an MUE is a claim line edit, not an entire claim edit, the claims processor should NOT sum all units of service for a HCPCS/CPT code on the claim or for the same date of service from prior claims in history with same date of service and compare this number to the MUE value. (10) Caution: A provider may report the same code on more than one claim line, when appropriate, appending a modifier to the code on the second and additional claim lines. The MUE value for the HCPCS/CPT code should be applied separately to the UOS reported on each claim line. (11) Caution: Claims processors may consider developing duplicate claim line logic to prevent providers from misusing modifiers to report the same code on more than two lines of a claim. Caution is necessary when developing this type of duplicate logic. (12) Caution: MUEs should NOT apply to any code reported with modifier 55. (13) Caution: For surgical procedures for which the code describes a unilateral procedure that can also be performed bilaterally, the MUE value is generally set as 1. The preferred way for providers to bill a surgical procedure that is performed at a single site on each side of the body is to bill the code on a single claim line with modifier 50 appended to the code and one UOS. Alternatively, the state can instruct providers to bill a bilateral surgical procedure on two claim lines (e.g., one with the RT modifier and one UOS and the other with the LT modifier and one UOS), but this is not the recommended approach. For radiologic procedures, other non-surgical diagnostic procedures, and durable medical equipment that can be performed or used bilaterally, the MUE value is generally set as 2 to permit the billing of bilateral procedures / items on a single claim line with two UOS. As with surgical procedures, states have the option to instruct providers to report bilateral procedures / items on separate claim lines. MUEs should not be bypassed by the modifiers that are appended to codes to indicate bilateral procedures. A state s Medicaid Management Information System (MMIS) should be configured to enable it to apply three types of edits to Medicaid claims in the following order: (1) State and contractor Medicaid edits, other than those identified in (2) and (3) below. These edits include, but are not limited to, edits that screen incoming claims for duplicate services, missing information, and modifiers which are inappropriately appended to a HCPCS/CPT code and edits that address eligibility, invalid HCPCS/CPT codes, coverage, medical necessity, and prior authorization (if required). (2) Medicaid NCCI PTP edits and MUEs (3) State and contractor PTP edits and unit-of-service (UOS) edits Page 33 of 54

34 MII WEBSITE FORMATS MUE COMPLETE EDIT FILES The NCCI Medically Unlikely Edit (MUE) complete edit files are posted to the MII website in three formats. The specifications for each format and sample screen prints have been included on the following pages. The three formats are: 1. Fixed-Width ASCII Text 2. Tab-Delimited ASCII Text 3. Excel 2007/2010 Fixed-Width ASCII Text Format (1) In the MUE MII website edit files in fixed-width ASCII format, each edit will have the following format: (2) There will be three separate final MUE MII website edit files: (a) Practitioner MUE edit file named MCD-MUE-PRA-vXXXXqX-FX-T.txt There is one edit file that applies to: (i) Practitioner services AND (ii) Ambulatory surgical center (ASC) services. (b) Outpatient Hospital MUE edit file named MCD-MUE-OPH-vXXXXqX-FX-T.txt There is one edit file that applies to: (i) Outpatient hospital claims including DME billed by the hospital (including critical access hospitals) (ii) Hospital Facility emergency department claims (including critical access hospitals) (iii)hospital Facility observation services (including critical access hospitals) (iv) Hospital Facility outpatient laboratory services (including critical access hospitals) (c) Durable Medical Equipment (DME) MUE edit file named MCD-MUE-DME-vXXXXqX-FX- T.txt. There is one edit file that applies to: (i) DME billed by DME providers (a) Does NOT apply to DME billed by practitioners. The MUE file for practitioners contains MUEs for DME billed by a practitioner. (b) Does NOT apply to DME billed by hospitals. The MUE file for outpatient hospital services contains MUEs for DME billed by a hospital. Note: Refer to page 7 for details of file naming convention. Page 34 of 54

35 Field Name Notes Type Beg. Char. # of Char. HCPCS/CPT Code (no label) AAAAA Alpha-Numeric Text 1 5 Maximum Units Allowed (no label) CLEID (no label) NNNNN formatted with leading zeros (e.g., an MUE of 11 will be written as 00011) Correspondence Language Example Identification Number format: DD.EEEEEEEEE The first 2 digits correspond to the Standard Policy Statement for the edit. The digits following the. correspond to the section of the Medicaid Correspondence Language Manual from which an example can be extracted to incorporate into correspondence such as provider inquiry responses. The last four characters of the CLEID field may contain empty spaces. When an MUE is terminated, the CLEID will be changed to 16.DELETEPR5, which corresponds to the deleted edit language and example in the Correspondence Language manual Numeric 6 5 Alpha-Numeric Text Effective Date (no label) Julian date format: yyyyddd Numeric 23 7 Deletion Date (no label) Julian date format: yyyyddd Edits with <blank> Deletion Date values are ACTIVE from the date in the Effective Date field. Numeric 30 7 Page 35 of 54

36 Field Name Notes Type Beg. Char. # of Char. Publication Indicator P Numeric 37 1 Valid values = 0 or 1 0 = not published confidential Do not share for use by CMS/CMCS and its contractors ONLY (currently no MCD MUEs have an indicator = 0) 1 = published - ok to share The following is an example of a section of a fixed-width ASCII text MUE MII website edit file: Page 36 of 54